Advances in Laparoscopic Liver Surgery for Liver Cancer

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals. Exploring the latest, innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase I and Sarcoma Programs. Today I'm happy to be joined by Dr. David Kwon. He's the director of laparoscopic liver surgery here at Cleveland Clinic. He is here today to talk to us about advances in laparoscopic liver surgery for liver cancer. So, welcome David.

Choon David Kwon, MD, PhD: Oh, thanks. Thanks for having me.

Dale Shepard, MD, PhD: So maybe to start, you can just give us a little bit of a background what your role here is at Cleveland Clinic.

Choon David Kwon, MD, PhD: Okay. So I joined Cleveland clinic about two and a half years ago. The purpose of my hire at Cleveland Clinic was to improve the laparoscopic liver surgery program that was already here. It was relatively small scale and so they wanted to improve the minimally invasive approach and liver surgery. And in addition to that, they also want to have some pieces of laparoscopic living-donor program. So they reached out to me and things worked out well so that I could join the team.

Dale Shepard, MD, PhD: Excellent. So we have a fairly general audience here, so maybe we could just start off fairly basic. What are the biggest advantages of a laparoscopic approach for liver surgery compared to an open procedure?

Choon David Kwon, MD, PhD: A laparoscopic approach, not only liver, but let's say colorectal cancer or pancreatic cancer and any cancers in the abdominal cavity... By having this minimally invasive approach, usually patients end up having less pain to recovery. The recovery is faster. They go home earlier and the over and all they return to normal activity a little bit early. So that's the general known benefits of a laparoscopic approach.

In addition to that, when you apply this technology in liver resection in liver cancers, there are a couple of other benefits that are only really very liver specific. And one of them is if you do it properly, actually you can have less bleeding during the surgery because of the intra-abdominal pressure works against the vein bleeding that is usually apparent in liver resection. And secondly, in patients with cirrhotic backgrounds, because of the minimally invasive approach itself. In a lot of patients, with cirrhotic backgrounds, they tend to have a lot of ascites after operation. And because you're not sacrificing a lot of the collaterals that have been developed around your abdominal cavity, actually end up having less ascites post-op, which is the thing of added benefit when you do a minimally invasive liver cancer.

Dale Shepard, MD, PhD: When you mentioned patients with cirrhosis, oftentimes they have a lot of other comorbidities. Is it possible sometimes to do surgery in those patients that may not be candidates for surgery otherwise?

Choon David Kwon, MD, PhD: The indication for surgery itself is almost identical to open versus laparoscopic. We don't have enough evidence as for now that we are able to expand the indication for surgery, but there is enough data that we understand that by having a minimally invasive approach, the patients end up having less post-operative ascites, and they have overall a much quicker and better recovery.

Dale Shepard, MD, PhD: When we're thinking about cancers related to the liver, are you primarily working in primary liver cancers, HCC, or is this also expanding into metastatic disease and removal of mets from the liver?

Choon David Kwon, MD, PhD: Well, if you look at the history of a laparoscopic approach, we initially used to do it for single lesions, and again because of this added benefits in cirrhotic, the first target patient population was hepatocellular carcinoma, primarily liver cancer. With more experience now added on, more and more cases with colorectal liver metastases or other metastatic lesions to the liver are being candidates of laparoscope approach. The main big hurdle in being able to apply this minimally invasive approach extensively as in open... Is usually metastatic lesions occur in multiple lesions at the same time. And if there are too many, then it adds a lot more operative time, which is one of the drawbacks of laparoscopic liver. Just as a brief example, usually in cases where you have more than five metastatic lesions, they're usually not candidates of laparoscopic approach. They'll be better managed by open approach because of the extensive resections that it required, but usually there are cases that are less than five. You can have a lot of benefits with laparoscopic.

Dale Shepard, MD, PhD: So in another episode of this podcast, we're going to talk to Dr. Eren Berber, who does a lot of ablations. How would something like a laparoscopic approach to resection compare to an ablation?

Choon David Kwon, MD, PhD: So ablation as for now, lesions that are less than three centimeters... The results for ablation and resection almost similar. At least for less than two centimeters they're the same. Between two and three centimeters, there is a lot of debate. Lesions that are above three centimeters, usually resection does a better job than ablation. But the good thing about ablation is not either surgery or ablation. Again in, especially in cases with metastatic lesions, some lesions are better managed by resection and some lesions are better managed by ablations and they can be done at the same time. So let's say you have four lesions spread out throughout the liver. Two of them requires resection and two of them can be managed by ablation. Then you apply both technology at the same time, at one time. So one surgery, two resections, and two ablations, and the patient can go back home early.

Dale Shepard, MD, PhD: You've mentioned some issues related to the number of lesions and size. What kind of patients would you like to see in your clinic? Who should be coming to see you to consider these approaches?

Choon David Kwon, MD, PhD: I think it's very important to understand that the way other specialties approach the case is a little bit different from the way surgeons look at it. I would recommend, unless it's completely widespread, to knock on the doors of surgeons to understand the perspective of the surgeon. If you look at the recent data coming out, actually there is quite a bit of patients that can be well down staged with chemotherapy or radiotherapy or other low collagenal modalities. That can be down staged at the extent that you can... Initially cases that were not deemed to be curable, can actually receive a curable chance by having a resection done after being properly down staged.

So I think it's very important to at least understand that whether your case will be a good candidate for being downstage and then probably be resected or not. And those things are really hard to make a proper decision. Whether you're a surgeon or whether you're a oncologist, this to be a group approach and therefore I would recommend any cases that have liver metastases, to at least having a consulting, an opinion from a surgical standpoint.

Dale Shepard, MD, PhD: I mean, certainly we have a well-established tumor board system as well, that we get that multidisciplinary input as well.

Choon David Kwon, MD, PhD: Yes. So our liver tumor board, it's fantastic. We have outstanding interventional radiologist, you have a superb team of external beam radio oncologist. And every tumor is a little bit different. So by applying all this different multidisciplinary approach for the same lesion, actually yields the best results.

Dale Shepard, MD, PhD: So how widespread is laparoscopic approaches like this? Is this something that mostly patients would have to come to academic centers to get optimal care from a laparoscopic approach? Or is this sort of widely available in a lot of community settings as well?

Choon David Kwon, MD, PhD: If you look at overall the penetration rate of laparoscopic surgery in the United States, it is fairly rich 10 to 15%. So out of 100 patients that get liver resection, only a 10 to 15%, receives it laparoscopically. Apparently in small centers, a small wedge resection can be done, but any cases above that small wedges, it's better to be done at a HPV specialized centers, such as ours, because it requires a lot of more expertise to be able to manage that by a minimally invasive approach. And that's why the penetration remains within 10-15%. I would say maximum, you'd be 20-30%.

As for our clinic, I would say since last year... If you look at the data for last year, more than 50% of all liver resections that we've done here are done laparoscopically. Because we also take in major liver resections, right? Lobectomies, left lobectomies. They can be all done laparoscopically, but I would say very, very few centers. They don't have HPV specialty, the surgical department will be able to manage those things laparoscopically.

Dale Shepard, MD, PhD: What're the areas of research that you find most interesting at this point to improve the field?

Choon David Kwon, MD, PhD: Well, one of the emphasis that I placed a lot is because this technology is not still widespread among the general surgeons within the US, I ran a course last year. I'm hoping to run another course this year as well. Also be sharing the laparoscopic liver surgery hands-on program in one of the big conferences. So I think there has to be a lot of teaching and education because it's still... We can see that it's relatively novel. And there's an extensive learning curve related with this technology that needs to get addressed properly in order to safeguard how these technologies applied to the patients.

Dale Shepard, MD, PhD: So you mentioned education. So, certainly on the oncology side, we get a lot of people coming in to see us because their physician sends them. But then they're also just a lot of patients that take it upon themselves to come. Are most of your referrals from physicians or do you get patients coming in to see if laparoscopic surgery may be something appropriate for them?

Choon David Kwon, MD, PhD: Well, I guess I have a half and a half. It's a mixed bag. Half of my patients, I get referred from physicians. And then I would say the other half just Google, they just find out that in Cleveland Clinic, we have a very extensive laparoscopic approach. We have a very strong laparoscopic program. So instead of getting an open surgery from where they were, they come to me and ask whether this can be done laparoscopically. If that is possible, we do it.

Dale Shepard, MD, PhD: What're the sort of technical issues that may be coming into play to keep this from moving forward, and being more general there, are there particular things that need to be changed or what does the future look like in terms of this procedure?

Choon David Kwon, MD, PhD: Well, as for Cleveland Clinic, during the last two years... Again, before I joined, we barely had a 20% penetration rate for laparoscopic approach. So it took me almost a year to change the whole culture. And the way things are being approached now is a very, very different from the way it was two years ago. Now moving forward, for the whole US population, it'll be a little bit more challenging, but again as I described, I'm hoping to have a lot more mentoring programs running so that these technologies can be applied in other states that don't have access to these technology.

Dale Shepard, MD, PhD: You mentioned before about sort of the combined approach. What does it look like in terms of interacting with the medical oncologists in terms of... Oftentimes if I'm sending someone for ablation, I'm perhaps giving them chemo upfront to shrink size or try to minimize risks that it might be spreading somewhere else. Are you seeing patients where you would like to have had chemo up front or is there something from a multidisciplinary perspective that you would like to see changed in this area?

Choon David Kwon, MD, PhD: So, well, one of the things that is, I would say a very large number of the patients that we treat... Some of the patients, I get first, some of the patients the oncologists get first. You have a discussion, we decide, "Okay, let's downstage a little bit more." I mean, I could resect it, but if it's well downstage, the resection will be minimal and it would benefit the patient. So we have neoadjuvant chemotherapy first, or again as I said, radiation or radioembolization first to make the size smaller and more accessible for surgery. Then we usually reassess three to six months later and do the surgery, and then move on.

There is also another group of cases in which initially, as I said, was not surgically curable. And I would say that's one of the parts that needs to be worked on. But I think it's going towards the right direction. Instead quite often, patients who are initially thought to be not curable, they end up being classified within the group of patients that are not curable. And even though they had chances during the course of the treatment that it could be surgically removed... Those cases are not brought up back to the tumor board to have a proper discussion. And this thing is, I would say, spread out throughout the whole country, even the world. And so therefore this interdisciplinary approach, taking case to case back, having discussion, a proper discussion. I think it's very crucial for the best management of the patient.

Dale Shepard, MD, PhD: You had mentioned about primary liver cancer, hepatocellular carcinoma and the role of laparoscopic surgery, and I know you have the interest in transplant as well. HCC has had a tremendous growth in systemic therapies, and it's really changed a lot over the last couple of years. Have you seen a change in, specifically, with HCC in terms of what you're doing from a laparoscopic, either primary resection or transplant, as the systemic therapies have changed?

Choon David Kwon, MD, PhD: Not much. I guess we still need some more time to understand the impact of systemic therapy. Its role in down staging in cases that were not manageable surgically. Until now the data that we have, at least from having a laparoscopic approach for primary liver cancer, it is known that if your initial liver resection was done laparoscopically, the second operation, which usually ends up being the transplant... The result of the transplant, usually it's better because you have less adhesion. Because the initial treatment was done less invasive, now it's known that you have less blood loss, and the patients usually end up recovering faster when you do the transplant. So that part is already established. The role of down staging, this is another part that our tumor board is trying to change the culture and it's a very actively thought out right now.

For a brief example, there was a case a couple of weeks ago, which it was a cholangiocarcinoma, extensive cholangiocarcinoma. We thought it wouldn't work at all. The patient had radiation therapy and chemotherapy, and six months down the road, the tumor has shrunk. Now we're considering maybe doing some more cycles. And if their tumor stays stable over the course of six months or a year, then we could possibly take the patient back for transplant or for surgery. We also have some cases that... Well, I personally have some cases like that, portal vein tumor thrombosis, which initially was not categorized as they were transplantable at all. Having worked with our interventional radiology and external beam, they shouldn't do chemotherapy. They come to a stage in which they could be transplantable, there is no widespread recurrence for a whole year, and then they could be possibly considered for transplant or resection.

And I think with a novel chemotherapeutic agents that we have, we have one more tool to downstage better. So I think this trajectory of making more patients accessible for a curative option in a group of population that never was considered., I think we have a bright future there.

Dale Shepard, MD, PhD: Well you've certainly made big changes in that. You mentioned that within a year, you've sort of changed the culture of what's happening from a laparoscopic surgery perspective. What would you like the program to look like, in say five years. What's the goal?

Choon David Kwon, MD, PhD: Well, about almost now a decade ago, when I first started laparoscopic approach, I also had embarked on robotic because at the time, both robotic and laparoscopic were two choices for a minimally invasive approach. When I first did it, it was evident that laparoscopic was way better than robotic because of the instruments that are available laparoscopically are... We had a lot more choices compared to robotic.

Now the robotic, I think the generation changed four times since then. And now the new robotic platforms that we have is so much better than the ones that I initially did. So we are slowly thinking about moving a little bit more to the robotic side. Just one, let's say one brief example, would be a klatskin tumor or a hilar cholangiocarcinoma, which now is still at the take the patients as an open approach, because of the complexity of the surgery and reconstruction that is necessary. I think moving down the road, maybe five years later, those could be candidates for robotic surgery. So they can reconstruct the hypnotic indigenous to me and take all the cancer out properly, just as we were doing open surgery without the invasiveness.

Dale Shepard, MD, PhD: Well, you're certainly doing some exciting things. And we certainly appreciate all of your hard efforts for our cancer patients. So, appreciate all of your insights today.

Choon David Kwon, MD, PhD: No, thanks so much.

Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget you can access real-time updates from Cleveland Clinics Cancer Center experts on our Consult QD website at consultqd.clevelandclinic.org/cancer. Thank you for listening. Please join us again soon.